A man who was born with liver disease died at the age of 30 following a catalogue of errors by his local health board which - ultimately - prevented him from having a transplant.
Unbeknown to him Carl Nolan had cirrhosis - a life threatening condition - but when he became ill and visited Glan Clwyd Hospital in Bodelwddyn, Denbighshire, staff failed to tell him about his complaint and he went without any medical treatment for several years.
Eventually when his liver was failing Mr Nolan was admitted to hospital but died three days later.
In a report published today the Public Services Ombudsman for Wales says: "Had he been treated three days earlier, Mr Nolan should have recovered from the infection and had a chance of receiving a liver transplant. This opportunity to survive and flourish was denied to him."
Betsi Cadwaladr Health Board has agreed to write to Mr Nolan's family to acknowledge its failings and pay them £5,500.